Provider Demographics
NPI:1558309039
Name:HASELWOOD, DOUGLAS MENZIES (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MENZIES
Last Name:HASELWOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N SUNRISE AVE
Mailing Address - Street 2:STE 1201
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2961
Mailing Address - Country:US
Mailing Address - Phone:916-965-3292
Mailing Address - Fax:916-965-3293
Practice Address - Street 1:151 N SUNRISE AVE
Practice Address - Street 2:STE 1201
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2961
Practice Address - Country:US
Practice Address - Phone:916-965-3292
Practice Address - Fax:916-965-3293
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25216174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42575Medicare UPIN
CA00G252160Medicare ID - Type Unspecified